Start  <  Monografien  <  Contents  <  Doctor and patient  -33-
Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Dialogue between doctor and patient - the nine steps from theory to application in daily medical practice
1. step - a critical self-appraisal
2. step - listening to yourself
3. step - optimizing the setting of the discussion
4. step - learning to actively listen and reflect
5. step - recognition of all messages in a signal
6. step - ability to empathize
7. step - learning to question and to stimulate questions
8. step - integrating the discussion to completion
9. step - establishing a mutual (common) reality
Dialogue between doctor and patient - 
the nine steps from theory to application in daily medical practice
The reader who has been patiently following, and is now prepared to change his approach (that is to talk to his patient with real understanding) will probably not without uneasiness ask how he can possibly translate his goodwill into reality under the pressure of daily clinical practice. Many terms are probably whirling around in his brain without clear order or classification: open and closed techniques, active listening, empathy, as well as first and second order reality. He is probably also wondering, how, with the best will in the world, the time available can be enough to allow him to speak to his patients in any other way than he has always done.

The way to apply theory in clinical practice is best accomplished by using single steps systematically. The following scheme should allow the reader to pursue this goal in nine stages. He is free to decide himself how long each will take. Initially he should perform a critical analysis of dialogues which he has followed previously, especially with regard to the quality and efficiency. Further steps are involved in the learning process about discussion, with a new orientation of standpoint, as well as one's reaction to the patient. The final stage is the most difficult, as the ballast of previous perceptions about the nature of reality has to be thrown overboard, in order to recognize that it is only possible for a doctor to communicate (in the true meaning of the word) with his patient when a mutual reality has been established.

If the reader is prepared to walk this path, he should go about it with a quiet and relaxed manner. All of the steps can be integrated "en passant" in daily clinical practice and do not require an additional time expenditure. The further the reader proceeds, the more often he will accomplish what he only occasionally experienced previously, and that is pleasure. Pleasure because he is experiencing what he can accomplish with the most important (but also most neglected physician's instrument) which is that of speech. The doctor's discourse becomes a treat to treat!
top top

First step - a critical self-appraisal
More than anything else, the first step requires a well-developed ability of self-criticism. It should allow an honest answer to the question: "Just how many of my discussions with patients are unsatisfactory for the patients, for myself or for us both?" The normal burden of the doctor's working day is often so great that the doctor is happy enough just to manage to perform all that is required of him. The question as to whether all the conversations were good, and satisfactory for both parties, can easily be dismissed as unimportant. However unsatisfactory discussions do not, as it were, lie quietly under the carpet.

If the patient is dissatisfied, this discontent can be expressed in several ways. Only in very rare cases will the patient say directly that he was disappointed with the consultation. This dissatisfaction is more likely to be expressed in a non-verbal form. The result of an unsatisfactory conversation is likely to manifest itself in the behaviour of the patient who reacts with aggression, rejection or anxiety. He comes back with the same queries. Compliance is unsatisfactory. He refuses useful investigations and suggestions for therapy. He gives the impression that he does not understand us, and that we have not understood him. He displays "difficult" behaviour. He repeatedly comes with the same complaints, or perhaps never comes again.

Obviously there are some conversations which the doctor well knows to have been a failure. However in many more cases he will be aware only subconsciously that he has conducted unsatisfactory consultations.

Unsatisfactory conversations with patients have a particularly stressful effect; they soon lead to tiredness, which expresses itself by irritation and aggression. They create the impression that one does not want to see the patient again in the near future. If he does come again, one sighs and attempts to subdue the sense of antipathy. After the discussion, one is left with the feeling that the whole of the interview consisted of shots in the dark. Nothing appears to have changed; in fact just the opposite - the situation has become more consolidated or the dialogue has produced further difficulties rather than solving the original problems. The treacherous deception is that the conversation which is unsatisfactory for the doctor, can insidiously be quite satisfactory (on a superficial level) for the patient, as it may have been "reassuring", without him being aware that all mentions of the actual problems were suppressed, deflected or minimized.

Throughout several days, ask yourself after each conversation if it was satisfactory; and if it was unsatisfactory, was it so for the patient, for yourself, or for both participants in the discussion. The results of this "internal self-analysis" can be decisive in motivating you to conduct consultations differently in the future. A further method of assessing the quality of your own technique is to ask colleagues for their critical opinion. Finally, it can be very helpful to record the conversation on video, provided that the patient does not object.
top top

Second step - listening to yourself
Listening to what one actually says is also an exercise in self-criticism, which can at the same time become the starting point for assessing if, and to what extent, it is necessary to improve one's techniques of leading discussions. The following points should be borne in mind when critically listening to oneself:

Is my questioning technique adequate and effective? Am I clearly showing empathy? Am I actively listening? Do I make room for pauses in the discussion and am I able to tolerate them and to interpret their significance correctly? What sort of terminology am I using? Is there "communication noncommittalism"? How often do I use impersonal terminology (such as that prefaced by "one", "it", "we"), "Yes, but ...", undefined qualifications, generalizations, exaggerations, duplicity (Trojan horses) or "killer phrases"? Does my way of talking produce anxiety? Do I use refusal techniques (deflection, evasion, minimization, incapacitation)?

Having looked at these aspects of speech, it is important to perform an analysis of the content. Was the conversation appropriate to the particular goal set for it? For example, was it possible to motivate the patient? If the patient was anxious, was the conversation aimed to deal with it? Was the "difficult" patient accepted and included in the conversation? Were there conflicts present, either in the subjects chosen for discussion or in the doctor-patient relationship, and was it possible to change an insoluble conflict situation into a problem solvable by means of discussion? Did the discussion take into account the differences encountered if the patient is old or chronically sick? Were the requirements of both the patient and of the team met during the ward round? Did the discussion with the patient on the intensive care ward take into account his need and difficulties with communication? Were conversations with seriously ill or dying patients in essence genuine? Did the discussion cease if the patient posed questions, even indirectly, about the reason for illness or his being ill, or about God, or about what happens after death?
top top

Third step - optimizing the setting of the discussion
Even though willingness to conduct good dialogue is present, the setting and environment can interfere with satisfactory conversation. Experience shows that the setting of a medical interview, whether in general practice or in hospitals, is often criminally neglected. Conditions which could not be tolerated by a public authority (or bank or airline company) are taken for granted in medical practice. However the setting of the interview largely decides on the fate of the discussion.

Watch out for the following points:
Is your discussion as uninterrupted as possible?
Are disturbances, caused by colleagues or assistants, telephone, intercoms, or other patients, minimized or kept under control?
Is the place where the discussion takes place appropriate (no corridor discussions, no standing in the doorway)?
Are the distances and seating correct?
Is the timing of the conversation correctly chosen (for example, a cancer patient should not be given the diagnosis in the evening, and a positive HIV result should not be discussed on a Friday afternoon)?
Are obvious signs of hectic activity and time-pressure avoided?
Overall, is the climate suitable for a discussion?
top top

Fourth step - learning to actively listen and reflect
An important sign of a good doctor is that he has a good listening technique. This is the most important skill that a doctor uses during interviews with patients. So now test yourself to see whether, in general, you are a good listener. Make it clear to yourself that you will often achieve more by active listening than by good questioning technique.

Watch your behaviour during conversations: do you tend to cut your patients short?

Are you able to cope correctly with pauses in conversation? Do you allow enough pauses (time for thought, communicative pauses) to encourage the patient to speak more? Do you know the various reasons for pauses which inhibit or block discussion? Are you able to tolerate breaks or silence during a conversation?

Active listening and reflection (mirroring) especially by verbalization of emotional experiences are very intimately related: the ideal drive for perceptive discussion is the integration of listening and expressing understanding.

Next, observe which are the basic conditions for active listening:
Interest in the subject, being prepared to listen, ability to hear and ability to be "completely present".

Let your partner in conversation know, without any doubt or misunderstanding, that you are truly and completely intent on hearing what he has to say (readiness to listen). It is the interlacing of speaking and active listening which forms the basis of successful discussion. Never interrupt your partner, as interruption is the absolute opposite of active listening, and a prime destroyer of discussion. If at first you become uncomfortable whilst actively listening, feeling that you should not take as much time over this, you should remember that experience has shown just the opposite: active listening saves time, inattention costs time.
top top

Fifth step - recognition of all messages in a signal
Rid yourself of the preconception that a signal only contains one message (factual content). Consider that speech is more than something that takes place when two computers communicate: any statement can contain up to four messages:
1. Factual information
2. Self-revelation
3. Relationship (contact)
4. Appeal

Attempt to examine the statements of your patients systematically, using the following four questions:
1. What is the factual content of the statement?
2. What does it show me about the person with whom I am speaking?
3. What is he trying to express about me and/or our relationship with this statement?
4. Is he trying to achieve something, and if so, what?

The most common mistake is that the message heard is only "factual information", and that the possible message about the relationship remains unheard. Check therefore what the true major message actually consists of. Develop an ear for hearing if the statement contains an implicit as well as an explicit message.

Do not forget that silence represents a special form of signal on the part of the one who says nothing, and that it can contain all the messages that are contained in the spoken statement. Check whether one or other of your "hearing ears" is larger than the other; it is usually women who tend to listen with a particularly sharp "relationship" ear, whereas men tend to receive reports with their "factual" ear. Always make it clear that you can work with all the messages you receive; they are tools. Do not forget that while communication is being carried out on the reporting level, communication is also proceeding on the meta-level in the sense of implicit metacommunication. In other words, be aware of the "that's what is meant" part of a signal.
top top

Sixth step - ability to empathize
Empathy is a comer stone of the understanding discussion. It is a bridge which leads from one's own perception of reality into that of the patient, and allows mutual reality to be found. Next: do not be afraid to use an empathetic approach! You will gain at least as much as you have to put in. Be clear that empathy should not be mistaken for sympathy, emotional involvement, fellow-feeling or identification with the patient. Think about the definition of empathy: "Empathy means to draw as completely and closely to the experience of the other, as though it were one's own, never once losing the "as if" status. If this "as if" status is lost, identification has taken over from empathy.

If you find it difficult to behave empathetically, you should remember that for most doctors, the desire to assist the suffering was decisive in the choice of becoming a physician. Later experiences and self-protective mechanism often prevent the realization of this original desire.

Further take into consideration two major hurdles that can prevent empathy. One is the need for "emotional neutrality" and the other, the need to dominate. The "genuineness" of your conversations with your patients is a good criterion for judging whether you are capable of empathy.
top top

Seventh step - learning to question and to stimulate questions
Now that you are more clearly aware of the possible pitfalls in conducting consultations; that you have created an atmosphere which in optimal for yourself, and are in a position to listen actively; that you are able to receive information from more than what is said, and to behave empathetically, you are now in a position to utilize your discussion technique and to learn the art of questioning. This involves differentiating between open and closed questions and being clearly aware of the advantages and disadvantages of each. Closed questions are probably better for obtaining immediate and objective information rapidly; they are less useful for initiating or deepening discussion. Open (non-structured) questions are appropriate for opening a discussion and for delving into a particular area. Semi-structured ("serving men" questions) are appropriate for throwing light on specific points.

Your questioning technique is good when you succeed in stimulating the patient to describe in his own words what it is that moves or troubles him. A metered number of sounding, catalogue and reflection (echo) questions can help. Systematically reject inappropriate questioning techniques whilst steering the conversation. These include leading, double and confrontation questions (unproductive questions) together with the complete range of forbidden questions (snare/trap, curiosity, judgmental, aggressive and flowery [rhetorical]). The more you succeed in improving your questioning technique, the more you will acknowledge that the good question is already a part of therapy. However, even when your questioning technique is optimal, you should not lose sight of the fact that active listening often brings more to light than any question, however discerning.

Finally do not forget to consider the questioning behaviour of your patient. What are his real reasons for asking (need for information, desire for attention, cry for help)? Why does he ask that at this particular moment? Is there a question behind the question? Why does the patient repeatedly ask the same question? And are you alerted if the patient does not ask anything (anxiety, time pressure, barriers to communication, incompatible realities)?
top top

Eighth step - integrating the discussion to completion
Many discussions between doctor and patient are only a torso; there is no "constructive beginning", the thread of the conversation is not adhered to, and a clear summary is missing. Proceed systematically. Take into account that every conversation has its own "previous history", and should come up to mutual expectations. With few exceptions, every conversation should include the following phases: opening - adaptation - examination of the subject matter - closing.

The various phases in the conversation are associated with different degrees of difficulty, and require different questioning techniques. The most difficult phase is opening the discussion. It is usually the stepping stone for all the subsequent discussion. Remember Goethe's maxim: "He who misses the first button hole, does not complete the buttoning". Ascertain at the beginning of the conversation where your patient stands, and start from where he is, not from where you are yourself. Go to where he is. Make use of the technique of "funneling" as a principle for steering the conversation; use open questions and widen the room for disclosure (open question technique), followed by narrowing the field in which answers can be given in order to focus the subject of discussion. Manage your discussions in the person-to-person situation. Remember that successful dialogue is only possible if patient is able and prepared to speak, and he is not inhibited or distracted by the environment. Its success also depends on whether or not it is possible to lead the interaction optimally by a combination of questioning, listening and intervening whilst concurrently correctly interpreting the verbal and non-verbal messages of the patient. Recognize when anxieties are affecting the patient. Do not forget that it is easier to diagnose than to interpret a disease.

Do not neglect that part of the discussion which is the most important in other professional discussions (selling a car or request of a loan), namely closing the discussion. This has several functions: what has been achieved and what not? What is now the position of the patient? Did the conversation fit mutual realities? Taking stock of the discussion is a basic requirement for the constructive plan, i.e. prescriptions, advice, recommendations, suggestions as to how these can be achieved and finally (if necessary) fixing a time for another discussion. A satisfactory discussion is formal and structured, with content and subject kept within bounds.
top top

Ninth step - establishing a mutual (common) reality
The last step on the path of perceptive discussion is the most difficult. It involves basic rethinking in two particular regards: in one instance, despite often deeply ingrained preconceptions, radically changing your thinking about reality. Rethinking is also required because your approach to the patient will become completely changed by this new apprehension of reality. This last step, which is to communicate with the patient from a fresh understanding of reality, is the most decisive step in understanding discussion. If this does not happen, the doctor is completely prevented from entering the world of his patient.

The initial condition for the achievement of this last step is to jettison the ballast of the old familiar preconception that there is only one single reality; a fallacy that Watzlawick calls "the most dangerous of all self-deceptions". Only when you have understood that there is "no absolute reality" in discussion, but only subjective views of reality (which can be completely opposed to one another), can one be released from the assumption that one's own subjective reality is "true" reality. You must also become acquainted with the fact that there are various degrees of reality.

The first degree is based on the consensus of opinion of those involved, and on experimentally repeatable and thereby verifiable evidence. One's own (that is, subjective) reality is in fact reality of the second order. The implication of this is that for one and the same thing, there are very many second order realities, which are seen as "real" by those involved. As the second order is as convincingly "real" as the first, there is a great danger that the difference will be completely overlooked and we remain completely unconscious that there are two different degrees of reality. It is impossible to understand a patient unless we are prepared to accept the idea that the reality of the disease to him is probably a completely different reality to that which we perceive, and that each of these two subjective realities (that of the doctor and that of the patient) are equally "real".

The nine steps to successful conversation between doctor and patient
The nine steps to successful conversation between doctor and patient

When you have accepted this concept, you have overcome the most decisive obstacle of all. There is no longer the danger that you will conduct your discussions with your patient as if you were two players in a board game, unable to play a game together because one was playing according to the rules of chess and the other to those of backgammon. As long as both players are unable to find a mutual code so that they can both use the same rules (that is to find a common reality), it will be impossible for them to agree.

After this conceptual hurdle has been overcome, you will be sure that the problem of communication is nothing other than a search for common rules of play or mutual codes. As long as each is an "outsider" to the reality of the other, communication is not possible. Communication is the joining of two separate realities by constructing a common reality.

Accepting that the reality of your patient and your own are different, the next step is clear; you must discover the patient's reality; where he is coming from, where he is now, what moves him, what he would like, and everything from his point of view. Empathy is the key to your approach.

Once you have understood your patient's reality, the final step is to build a common reality together with him. The identical reality of patient and doctor now opens up the possibility of communication with a common frame of reference, and each comprehending the other. When this is accomplished, doctor and patient will have achieved the highest point possible in their dialogue. 

top top
previous page previous page
next page next page
Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
URL of this page:
Start  <  Monografien  <  Contents  <  this page: Doctor and patient  -33-